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Virtual Scientist Survivor Program at the AACR Annual Meeting New Applicant Application

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Please complete this application in its entirety including the advocate poster section and letter of support. The application deadline is Friday, January 8, 2020. Applicants will be notified of their status by mid- February. Conference dates to be announced.

Please note, you cannot save your application online. Applications must be completed in one sitting. It is highly recommended that you review the application questions in the pdf. document prior to

completing the application.

Incomplete applications will not be considered.

Applicant Information.

Virtual Scientist↔Survivor Program at the AACR Annual Meeting 2021 - New Applicant

Application

Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number 1. Applicant *

2. Please state your gender. *

Male Female

Genderqueer/Non-Binary Prefer not to disclose Fill in the blank

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Other (please specify)

3. Please check the descriptions below that correspond to the racial/ethnic groups which you most identify.

Check all that apply.

*

African American / Black Alaskan Native

Asian Caucasian

Hispanic / Latino Native American Native Pacific Islander

If cancer survivor or patient, please identify the type of cancer.

4. Please check the box that best describes you. Please note, you do not need to be a cancer survivor to be

accepted into the program.

* Caregiver Cancer Survivor Currently In Treatment Metastatic Patient Research Advocate Policy Advocate Fundraising Advocate Other

5. Please indicate and rank the top three organ site/focus of your advocacy . *

All cancers

Brain cancer

Breast cancer

Colon & rectum cancer

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Head & Neck cancer

Kidney cancer

Leukemia / Lymphoma

Liver cancer

Lung & Bronchus cancer

Melanoma Multiple Myeloma Ovarian cancer Pancreatic cancer Pediatric cancer Prostate cancer

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Reproductive cancer

Sarcoma & Soft Tissue cancer

Skin cancer

Stomach cancer

Thyroid cancer

Uterine Cervix

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General Advocacy Information

Virtual Scientist↔Survivor Program at the AACR Annual Meeting 2021 - New Applicant

Application

None (no direct knowledge/experience)

Mid-Level (have some training/familiarity)

Above Average (have had science education training/experience) Knowledge of cancer research Understanding of policy issues (funding, lobbying) Level of involvement in patient support and public education Level of involvement in cancer research

6. Rate your educational background and/or experience in the following areas. *

If yes, please list the program(s) you have participated in.

7. Have you attended advocacy trainings or mentorship programs? *

Yes No

If yes, please list the grants or review boards you have participated in.

8. Have you served as a cancer advocate on any grants or review boards? *

Yes No

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9. Please provide a detailed biography describing your involvement in cancer-related advocacy. (If selected,

your response will be included in program materials.) Please do not list accomplishments.

*

10. What are your current advocacy priorities and plans for the year 2021? *

11. What would you like to gain from your participation at the Scientist↔Survivor Program? How do you think the AACR Annual Meeting 2021 will help you enhance your ability to serve your constituency?

*

Topic Topic Topic Topic

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13. How did you hear about this training program? *

Scientist/Researcher Advocate

AACR Newsletter / Email AACR Website

Other (please specify)

14. Do you have a financial and/or business interest in, consult for, and/or receive funding from (including

honorariums and travel reimbursements) a pharmaceutical company? Yes

No

If yes, please specify in what capacity and pharmaceutical company.

No file chosen

15. Please provide a letter of support from a colleague. *

Choose File Choose File

Twitter

16. If public, please provide your Twitter handle(s).

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Each accepted advocate must present a poster during the conference. Please note: topic and description can change if accepted.

Advocate Poster Session

Virtual Scientist↔Survivor Program at the AACR Annual Meeting 2021 - New Applicant

Application

17. Title of Poster *

18. Please provide a draft description of your poster. The description should include information on your organization's mission, initiatives, programs and constituencies.

*

19. Are you applying as a representative of an organization?

Yes

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Independent Advocate.

Virtual Scientist↔Survivor Program at the AACR Annual Meeting 2021 - New Applicant

Application

20. Briefly describe your constituency. *

21. Do you serve racial/ethnic minorities, the underrepresented, and the medically underserved?

Yes No

If yes, please specify.

22. How do you serve your constituencies? *

23. What programs and/or initiatives are you currently involved in? *

24. Have you been involved with any advocacy organizations? *

Yes No

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Organization

Virtual Scientist↔Survivor Program at the AACR Annual Meeting 2021 - New Applicant

Application

25. What position do you currently hold within the organization?

Founder Executive Director Staff Officer Board Member Volunteer

Other (please specify)

Organization Name Executive Director / CEO Address Address 2 City/Town State/Province ZIP/Postal Code Country Executive Director's Email Phone Number 26. Organization * 27. Organization Website *

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28. Please provide a brief description of the organization. Description will be printed in program materials. *

29. Briefly describe the organization's programs and services. Please limit your response to 250 words. *

30. Briefly describe the constituents you serve.

31. Do you serve racial/ethnic minorities, the underrepresented, and/or the medically underserved? *

Yes No

If yes, please specify.

32. Approximate number of constituents served annually: *

33. How many years has the organization been in existence? *

Less than 1 yr. 1-5 yrs.

6-10 yrs. More than 10 yrs.

34. What is the geographic scope of the organization? * National Regional State Local International

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35. Does the organization have the following. Check all that apply.

501(c)3 status A board of directors A newsletter

Research grant program Policy program

Patient support program Other (please specify)

Twitter Facebook

36. Please provide the organization's social media handle(s).

37. Has your organization been involved in the Scientist↔Survivor Program in the past? * Yes No Name Name Name

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Submitting this application DOES NOT confirm that you or your organization will be selected to participate in the virtual Scientist↔Survivor Program at the Annual Meeting 2021. The selection process is competitive, as there are a limited number of spots available.

Advocates may only participate in the Scientist↔Survivor Program at AACR Annual Meeting twice. Once you have exhausted your opportunities, you may apply as an advocate mentor. However,

acceptance into the virtual program will not be counted towards the two year quota for participation in the SSP at the Annual Meeting.

Applicants will be notified via email. Please add ssprogram@aacr.org to your contact list to remove from spam filter.

For additional information please contact:

Survivor and Patient Advocacy Program American Association for Cancer Research

Email: ssprogram@aacr.org

AACR is thankful to its supporters of the Scientist↔Survivor Program.

Thank you for completing this application.

Virtual Scientist↔Survivor Program at the AACR Annual Meeting 2021 - New Applicant

Application

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